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CASE REPORT Open Access
Cervical epidural hematoma after spinalmanipulation therapy: a
case reportQian Chen1†, Jun-fei Feng1†, Xin Tang2, Yu-ling Li1, Lu
Chen1 and Guo Chen3*
Abstract
Background: Cervical spinal manipulation therapy is a common
non-invasive treatment for neck pain and stiffness,and has been
widely used in the population. However, most people do not pay
attention to the potential risks ofneck manipulation, such as
ligament damage, fractures, and spinal cord injuries. Epidural
hematoma is a disease inwhich blood accumulates in the epidural
space of the vertebral body. This disease is usually caused by
trauma oriatrogenic surgery, and may be associated with blood
coagulopathies, neoplasms, or degenerative spinal disease.Reports
of epidural hematoma caused by cervical spinal manipulation are
rare.
Case presentation: We present the case of a patient with
tetraplegia and spinal shock after neck manipulation. Aphysical
examination of the patient on admission found tenderness in the
neck and increased muscle tension inboth upper limbs. The
superficial sensation of the upper limb disappeared, but the deep
sensation still remained.The lower extremity had 0/5 power on both
sides. The sensation below the T2 level completely disappeared.
Acervical magnetic resonance imaging scan showed an acute posterior
epidural hematoma from the C3–T3vertebrae. Ultimately, the patient
underwent emergency hematoma removal and showed partial improvement
insymptoms of paralysis during follow-up.
Conclusions: Although spinal manipulation is simple and neck
pain is common and recurrent in the generalpopulation, the basic
condition and disease history of patients should be determined
before manipulation. Forhigh-risk patients, caution should be
applied for cervical spinal manipulation or it should be
prohibited. For asuspected hematoma, MRI should be used at an early
stage to diagnose and locate the hematoma.
Keywords: Cervical epidural hematoma, Spinal manipulation,
Spinal cord injury
BackgroundCervical spinal manipulation therapy is widely
usedamong the people, and it is part of the complementarytreatment
for neck pain and stiffness. There are manymedical institutions and
non-medical institutions thatoffer various types of manipulation.
Although neck ma-nipulation is simple, the serious complications
caused byneck manipulation cannot be ignored, such as
vertebralartery dissection, spinal cord injury, cervical
subluxation,and cerebrovascular accidents [1, 2]. Cervical
epiduralhematoma is a serious complication after neck
spinalmanipulation and is rare. Few cases of severe quadriple-gia
caused by neck manipulation have been reported [3–
12]. Most of these cases suffered from various under-lying
diseases, such as coagulation dysfunction and cer-vical vascular
malformations. We report a patient withtetraplegia due to neck
manipulation. Our patient isunique because he had no history of
these diseases ormedication use.
Case presentationWe experienced a 55-year-old man who developed
tetra-plegia after neck spinal manipulation for stiff neck pain.The
patient was healthy with no significant medical his-tory and no
previous history of taking medication (thepatient denied taking
aspirin or any other anticoagulantmedications). But he had several
previous mild neckpains and was relieved after manipulation
treatment.The patient was treated with cervical manipulation andhe
felt pain and numbness in his lower limbs about 2 hafter the end of
the manipulation. The symptoms of his
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to the data made available in this article, unless otherwise
stated.
* Correspondence: [email protected]†Qian Chen and Jun-fei Feng the
co-first author, contributed to thismanuscript equally.3Sichuan
Provincial Orthopedic Hospital, Chengdu 610041, Sichuan, ChinaFull
list of author information is available at the end of the
article
Chen et al. BMC Musculoskeletal Disorders (2019) 20:461
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sensory abnormalities gradually worsened and spreadupwards. The
patient felt seriously ill and was immedi-ately sent by his
relatives to the emergency room of ourhospital to visit a doctor.
After being admitted to theemergency room, the patient was mentally
alert during aphysical examination. There was tenderness in the
neckand increased muscle tension in both upper limbs.
Thesuperficial sensation of the upper limb had disappeared,but the
deep sensation still remained. The lower extrem-ity had 0/5 power
on both sides. There were findings ofsensory deprivation at the T2
dermatome and below,and anal tone was absent with the
bulbocavernosus re-flex. An imaging examination was performed after
an in-dwelling catheter was inserted. There were no
abnormalfindings on a cervical vertebral X-ray and brain com-puted
tomographic (CT) scans. A cervical magnetic res-onance imaging
(MRI) scan showed an acute posteriorepidural hematoma from the C3
to T3 vertebrae (Figs. 1and 2). MRI also showed a large
heterogeneous collec-tion within the right lateral epidural space
of C4 untilT1, which was consistent with the hyperacute
epiduralhematoma, with cord edema at the same level (Fig. 3).The
hematoma resulted in spinal stenosis, the narrowestof which was
located at the C5 and C6 levels. There wasno evidence of vertebral
body fracture or subluxation.Clinical laboratory results at
admission were normal andblood investigations showed that platelet
counts werewithin the normal range with a normal coagulation
pro-file (Table 1). Subsequently, to exclude vascular
malfor-mations, the patient was scheduled to undergo CT
angiography. CT angiography showed no malformationof the neck
vessels (Fig. 4).We started intravenous prednisolone infusion to
the pa-
tient to alleviate spinal edema and to prepare for spinalcanal
decompression and evacuation of the hematoma.During the operation,
we saw a C4–T1 epidural hematomaand compression of the spinal cord
at the correspondinglevel, especially at the C5–C6 levels. The
hematoma was
Fig. 1 Sagittal MRI of the cervical spine (T1-weighted
image).Hypointense collection over the posterior aspect of the
spinal cordwith cord edema can be seen
Fig. 2 Sagittal MRI of the cervical spine (T2-weighted image).
Anarea of increased intensity from the C3–C7 levels can be seen
Fig. 3 Transaxial MRI of the cervical spine (T2-weighted
image).Compression over the right posterolateral aspect of the
spinal cordat the C5/C6 level can be seen
Chen et al. BMC Musculoskeletal Disorders (2019) 20:461 Page 2
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located in the right posterior part of the spinal cord, whichis
consistent with the results of MRI. The hematoma beganto thin below
the T1 level, and spinal cord compressionwas reduced accordingly.
Therefore, we only removed thehematoma at the C4–T1 levels.After
surgery, the patient was sent to the intensive
care unit for further treatment. On postoperative day 1,there
was some improvement in neurology, with areturning of upper
extremity strength from 0/5 to 2/5.Superficial sensation and deep
sensation between theT2–T8 levels changed from deprivation to
hypoesthesia.On the 7th day after the operation, the patient’s
symp-toms improved further. His upper limb muscle strengthincreased
to 4/5, but sensation below the T10 level wasstill absent. This
condition remained until he was dis-charged from hospital. During a
follow-up of 3 monthsafter discharge, neurological function of the
patient didnot greatly recover.
Discussion and conclusionCervical spinal manipulation is a
common practice, whichis performed by either professional or
non-professionalpersonnel, owing to its relatively few invasive
treatments.It is defined by the International Federation of
OrthopedicManipulative Physical Therapists (IFOMPT) as: “A
pas-sive, high velocity, low amplitude thrust applied to a
joint
complex within its anatomical limit with the intent to re-store
optimal motion, function, and/ or to reduce pain”[13]. The known
complications resulting from cervicalspinal manipulation include
cerebral stroke from localpressure on the blood vessels, ligament
injury or fracturesfrom excessive pressure or rotation, and spinal
cord injury[4, 14]. After cervical spine manipulation, the
estimatedincidence of serious adverse events ranges from 1 per
50,000 to 1 per 5.85 million manipulations [2]. According toreports
that the likelihood of injury following spinal ma-nipulation was
increased among patients with a chroniccoagulation defect,
inflammatory spondylopathy, osteo-porosis, aortic aneurysm and
dissection, or long-term useof anticoagulant therapy [15]. Epidural
hematoma is a dis-ease in which blood accumulates in the epidural
space ofthe vertebral body. This disease is usually caused bytrauma
or iatrogenic surgery, and may be associated withblood
coagulopathies, neoplasms, or degenerative spinaldisease. Reports
of epidural hematoma caused by neckmanipulation are rare, with less
than 10 cases reported[3–10]. Most cases occurred in the cervical
spine, not inthe thoracic or lumbar spine. Some of these cases had
cer-vical spondylosis or a history of oral anticoagulants.Table 2
summarizes the cases of epidural hematoma afterneck manipulation
[3–12]. In most cases, the location ofthe hematoma was either
posterior or posterolateral. Thehematoma in our case was located at
the right posteriorside. The pathological mechanism of spinal
epiduralhematoma remains unclear. The mechanism of spinal epi-dural
hematoma might be the same as that of intracranialepidural hematoma
[16]. However, some researchers be-lieve that spinal epidural
hematoma is caused by injury ofthe epidural venous plexus or a
sudden increase of venouspressure [16]. The incidence of spinal
epidural hematomais higher in patients with coagulation disorders
and inthose taking anticoagulants [17]. In a case reported byWhedon
et al. [5], the patient had to take coumarin for along time because
of atrial fibrillation and showed stiffnessafter neck manipulation.
Subsequent laboratory testsshowed abnormal coagulation function.
The results ofcoagulation-related examinations in this case were
normaland there was no history of taking anticoagulants (Table1).
Heiner [9] reported another interesting case in whichthe patient
did not have the above-mentioned risk factors.However, the patient
was pregnant at that time. Becauseof the change in venodynamics and
a decrease in venouspressure in the epidural space relative to
venous pressure,the pressure gradient of epidural vessels
increased, whicheasily led to epidural hematoma [18]. We observed
thatmost of these cases report scarcely description of the
clin-ical characteristics which are possible risk factors for
ser-ious complications in patients, such as smoking,
cervicaltrauma, recent infection, hypertension, etc. (This is
whereour cases are limited) It could be that the manipulating
Table 1 Clinical laboratory coagulation test results
Inspection item Quantitative results Reference value
PT 12.700 12.40–14.5
INR 0.9800 0.90–1.15
PT% 103.00 78.0–124.0
APTT 30.40 28.0–45.0
TT 15.20 15.0–19.0
Fig. 4 CT angiography of neck. CT angiography of the neck
showsthat there is no malformation of neck vessels
Chen et al. BMC Musculoskeletal Disorders (2019) 20:461 Page 3
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professionals did not see the need to report or were un-aware of
these items or were more focused on the treat-ment strategy and
recovery after hospitalization [13]. TheCARE statement was
published to guide transparency andaccuracy of case reports as well
as to improve the qualityof case reports [19, 20].Cervical spinal
epidural hematoma is usually charac-
terized by neck pain, scapular pain, and varying degreesof
neurological deficits [5]. An early MRI scan is neces-sary for this
type of patient, and it can accurately deter-mine the location and
severity of the hematoma.
Patients with mild neurological symptoms and a stablecondition
can be treated conservatively. In a case re-ported by Ryu et al.
[10], because the patient’s symptomsrapidly improved, no surgical
treatment was requiredand he was discharged in only 1 week.
Surgical treatmentshould be performed in patients with severe
neurologicaldeficits or progressive severe symptoms. In a case
reportedby Ling et al. [7], surgery was performed after the
patientwas admitted for tetraplegia after neck manipulation.These
authors believed an earlier surgical interventionwould have
delivered a better outcome and improvement.
Table 2 Summary of reported cases of cervical epidural hematoma
after spinal manipulation therapy
Reference Age (years) Gender Symptoms Level Location of hematoma
Treatment Outcome
Segal et al. 1996 [3] 33 Female Paraplegia C4–6 posterior
Surgery
Tseng et al.,2002 [6] 67 Female Hemiparesis C3–5 posterolateral
Surgery Recovery
Saxler G et al.,2002 [4] 27 Female Headache C1-S1 not reported
Conservative Recovery
Whedon et al.,2006 [5] 79 Male Lower extremity paralysis C2–4
posterolateral Surgery Recovery
Domenic- cci et al.,2007 [8] 52 Female Hemiparesis C4-T1
posterolateral Surgery Recovery
Heiner et al.,2009 [9] 38 Female Upper extremity paralysis C4
posterolateral Conservative Recovery
Meng et al.,2015 [11] 40 Male Upper extremity paralysis C2-T2
posterolateral Surgery Recovery
Fattahi et al.,2017 [12] 44 Female Tetraplegia C1–4 anterior
Conservative Recovery
Ling et al.,2017 [7] 33 Male Tetraplegia C4–7 posterolateral
Surgery Die
Ryu et al.,2018 [10] 38 Male Paraparesis C6-T1 anterior
Conservative Recovery
Present case 55 Male Tetraplegia C3-T3 posterolateral Surgery
Partial recovery
C cervical, T thoracic, S sacrum
Table 3 Contraindications and precautions to perform cervical
spinal manipulation [21]
Contraindications Precautions
(Acute) fracture Inflammatory disease
Relevant recent trauma Rheumatoid arthritis
Dislocation Ankylosing spondylitis
Ligamentous rupture History of cancer
Instability Long-term steroid use
Active cancer Osteoporosis
Acute myelopathy Systemically unwell
Spinal cord damage Hypermobility syndromes
Upper motor neuron lesions Connective tissue disease
Multi-level nerve root pathology A first sudden episode before
age 18 or after age 55
Worsening neurological function Cervical anomalies
Recent surgery Local infection
Acute soft tissue injury Throat infection
Unremitting, severe, non-mechanical pain Recent manipulation by
another health professional
Unremitting night pain Vascular disease
Vertebral / carotid artery abnormalities Blood clotting
disorders / alterations in blood properties
Vertebrobasilar insufficiency Anticoagulant therapy
Absence of a plausible mechanical explanation for the patient’s
symptoms
Immediately post-partum
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Our patient who had a severe nerve defect underwent sur-gical
treatment and achieved good results. Surgery pre-vented further
compression and edema of the cervicalspinal cord, which created a
favorable environment forsubsequent recovery of nervous
function.How to improve the safety of cervical spine manipula-
tion? It is important that every potential serious adverseevent
caused by vascular or other pathologies should beprevented. Thus,
thorough patient interviewing, clinicalassessment, interpretation
and analysis are significantcomponents needed to define an
indication for cervicalspine manipulation [21]. Table 3 presents a
summary ofcontraindications and precautions for cervical spine
ma-nipulation [21]. Cervical spine manipulation should notbe
performed when contraindications are present [17].Prior to
manipulation, a risk-benefit analysis should beperformed and that
includes the following three steps[21] :①identifying a possible
vasculogenic contributionor other serious pathology; ②determining
whether thereis an indication or contraindication for mobilization
ormanipulation; ③sessing the presence of any potentialrisk factors
associated with potential serious adverseevents which are reported
to occur after cervical spinemobilization and/or manipulation.
Potential risk factors,risk signals and contraindications can be
found in inter-views with patients and this information can provide
abasis to create initial hypotheses to be further investi-gated in
the clinical examination [22]. Physical examin-ation before
manipulation is also necessary, because theexamination of abnormal
sensory and muscular strengthof limbs maybe occur in patients with
cervical epiduralhematoma and a positive test can be regarded as an
indi-cator of the patient’s risk of getting severe
complicationsduring a cervical manipulation. Such as spinal
epiduralhematoma can present with features ranging from sim-ple
pain with radiculopathy to complete paraplegia orquadriplegia [23].
If we just adopt spinal manipulationbecause of stiffness and pain
in the neck and ignore theabnormal results of other physical
examinations, it maylead to serious consequences. The upper
cervical spineinstability tests and premanipulative vertebrobasilar
in-sufficiency tests these tests can be valuable in detectingupper
cervical spine instability or vertebrobasilar insuffi-ciency, but
their applicability as primary screening testhas yet to be
confirmed [24, 25]. Moreover, cervical ma-nipulation should not be
performed at the end of rangeof cervical movement, particularly
extension and rota-tion [22].In conclusion, neck pain is common and
recurrent in
the general population, but in the absence of neurologicalsigns
and symptoms, there is no practical, clinically validscreening
tests to identify underlying risks in patients withneck pain. So,
history taking and patient characteristicsare very important.
Patients with a suspected hematoma
should first be examined by MRI to make a definite diag-nosis
and guide further treatment.
AbbreviationsAPTT: Activated partial thromboplastin time; CT:
Computed tomography;INR: International normalized ratio; MRI:
Magnetic resonance imaging;PT: Prothrombin time; TT: Thrombin
time
AcknowledgmentsWe are grateful to the staff of our department
for their support andcontribution to this study. We thank Ellen
Knapp, PhD, from Liwen Bianji,Edanz Group China
(www.liwenbianji.cn/ac), for editing the English text of adraft of
this manuscript.
Authors’ contributionsGC, QC, and JFF designed this study. QC,
JFF, TX, YLL and LC wereresponsible for collecting, analyzing and
interpreting the data, and writingthe manuscript. QC and JFF
identified the case, performed the operation,and made contributions
to revising the manuscript for crucial intellectualcontent. The
final version of the text has been reviewed and approved by
allauthors.
FundingNo commercial, public, or nonprofit organizations
financially supported thisresearch.
Availability of data and materialsAll data analyzed during this
study are included within the manuscript. Thedatasets used and/or
analyzed during this study are available from the firstauthor on
reasonable request.
Ethics approval and consent to participateThis study was
approved by the Institutional Review Board at the
AffiliatedHospital of North Sichuan Medical College. Each author
certifies that allinvestigations were conducted in accordance with
ethical principles. Theparticipant involved in the study gave their
informed consent and signedand an informed consent form.
Consent for publicationWritten consent to publish this
information was obtained from the patient.Proof of consent to
publish from the patient can be requested at any time.
Competing interestsThe authors declare that they do not have any
competing interests.
Author details1Department of Orthopaedic Surgery, the Affiliated
Hospital of North SichuanMedical College, Nanchong 637000, Sichuan
Province, China. 2Zunyi MedicalUniversity, Zunyi 563000, Guizhou
Province, China. 3Sichuan ProvincialOrthopedic Hospital, Chengdu
610041, Sichuan, China.
Received: 9 April 2019 Accepted: 9 October 2019
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AbstractBackgroundCase presentationConclusions
BackgroundCase presentationDiscussion and
conclusionAbbreviationsAcknowledgmentsAuthors’
contributionsFundingAvailability of data and materialsEthics
approval and consent to participateConsent for publicationCompeting
interestsAuthor detailsReferencesPublisher’s Note